Does M25.279 require prior authorization?

No, M25.279 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`M25.279`, Flail joint, unspecified ankle and foot

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

The article provides billing and coding guidance and references LCD L39116; required documentation (e.g., medical records, prior authorization, specific forms) is not specified here and must be obtained from LCD L39116.
Billing, coding, and documentation requirements (e.g., required medical record elements, coding guidance, prior authorization if applicable) are specified in LCD L39139 and accompanying billing guidance; review LCD L39139 for the exact documentation required for claims.
This billing and coding article provides billing and coding guidance for Local Coverage Determination (LCD) L39575 regarding amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications.

Key Coverage Criteria

No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.
Coverage applies when the amniotic or placental-derived product injection/application meets the reasonable and necessary requirements of Local Coverage Determination L39877.
Amniotic and placental-derived product injections/applications are covered only when they meet the reasonable and necessary clinical requirements specified in LCD L39879 (Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound).
General orthosis/prosthesis criteria: prescribed by a physician, nurse practitioner, podiatrist or other health professional qualified to prescribe orthotics/prosthetics according to State law; the orthosis/prosthesis will significantly improve or restore physical functions required for mobility related activities of daily living (MRADLs); the participating physician/licensed practitioner has determined the orthosis/prosthesis will allow the member to perform ADLs based on physical examination; [...]
Ankle air-stirrups (e.g., Air Cast): medically necessary DME when used after an ankle injury (fractures or sprains).

9 Active Policies

A59434, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

AETNA-CPB-0669, Subtalar Implant for Foot Deformity

AETNA-CPB-0637, Osteochondral Autografts (Mosaicplasty, OATS)

AETNA-CPB-0565, Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs)

`M25.279`, Flail joint, unspecified ankle and foot

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

M25.279, Flail joint, unspecified ankle and foot

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

`M25.279`, Flail joint, unspecified ankle and foot